Tension-free vaginal tape procedure: an effective minimally invasive operation for the treatment of recurrent stress urinary incontinence?

The aim of this study was to evaluate the results of tension-free vaginal tape (TVT) surgery in women with recurrent stress urinary incontinence (SUI). Fifty-one women with recurrent SUI were treated with TVT and followed prospectively for a minimum of 2 years according to a protocol. Twenty percent of the women had already undergone two previous continence procedures, whereas 80% had undergone only one. The mean follow-up period was 25.3 months. The objective cure rate was 89.6%, and the subjective cure rate 80.4%. No serious complications occurred. The majority of the patients were discharged in the afternoon of the operation day. No significant difference was observed between pre- and postoperative residual urine, maximal urethral closure pressure, and total and maximum voided urine volume values. However, the changes in urinary frequency, minimum voided volume, pad test results, and visual analog scale scores were highly significant. TVT appears to be a safe and suitable treatment for recurrent SUI.     

The use of prophylactic antibiotics in the tension-free vaginal tape procedure: is it indicated?

The tension-free vaginal tape (TVT) surgical procedure is well established in the treatment of female urinary stress incontinence. The operation is based on a midurethral Prolene tape support. TVT is accepted as an easy-to-learn and safe minimally invasive surgical technique. Postoperative infections have been described following other surgical methods for correcting female urinary stress incontinence. Hence, prophylactic antibiotics are commonly also used in TVT to minimise this surgical complication. The aim of this analysis was to evaluate the occurrence of infection in relation to TVT and the need for prophylactic antibiotics. Out of 524 patients undergoing TVT and followed for up to 68 months, only three suffered surgical field infections within the postoperative period. The three infective processes developed with a background of retropubic haematoma formation. The literature is reviewed, and the justification for prophylactic antibiotics in the TVT operation is discussed.     

Transobturator vaginal tape for the treatment of stress urinary incontinence in elderly women without concomitant pelvic organ prolapse: is it effective and safe?

Objective

To evaluate the efficacy and safety of the transobturator approach (TVT-O) for the surgical management of stress urinary incontinence (SUI) in older women.

Study design

Between 2007 and 2010, all consecutive women with SUI undergoing an isolated TVT-O procedure were prospectively enrolled in this study. Patients were divided into two groups by age: older women (≥70 years old) were included in group 1, while younger women (<70 years old) in group 2. Intra- and post-operative outcomes were compared between the groups.

Results

During the study period 181 women met the inclusion criteria and were included for final analysis. Among these women, 60 (33.1%) and 121 (66.9%) were included in groups 1 and 2 respectively. After a median follow-up of 26 (IQR 15–41) months for the younger and 25 (IQR 18–40) months for older patients (p > 0.99), no differences were observed between the two groups in terms of cure rate (92.5% vs. 88.3%; p = 0.40). No differences were observed in terms of voiding dysfunction, vaginal erosion and persistent groin pain, or in terms of onset of de novo overactive bladder (9.0% vs. 13.3%; p = 0.44).

Conclusions

TVT-O appears to be a safe and effective procedure for the management of stress urinary incontinence also in elderly population.     

The suburethral sling for female stress urinary incontinence: a retropubic or obturator approach?

STUDY OBJECTIVE: To evaluate the feasibility and safety of the obturator approach for placement of a vaginal suburethral sling indicated for women with stress urinary incontinence. DESIGN: Retrospective cohort analysis (Canadian Task Force classification IV). SETTING: University teaching hospital. PATIENTS: Forty-nine women suffering from stress incontinence. INTERVENTION: Analysis of the suburethral sling according to surgical approach during two consecutive periods: retropubic from January 1, 2001 through September 30, 2001, and obturator from October 1, 2001 through January 31, 2002. MEASUREMENTS AND MAIN RESULTS: During the study period, 25 patients underwent surgery with the retropubic approach and 24 with the obturator approach. The patient characteristics did not differ between the two groups. The obturator approach was feasible in all attempted procedures. The mean operative time was 46 minutes (range 20-90) for the retropubic approach compared with 32 minutes (range 15-50) for the obturator approach (p = .03). Two bladder injuries occurred with the former, none with the latter (although cystoscopy was not routinely performed) (p = .49). Similarly, significantly more patients in the retropubic approach group had difficulty with postoperative voiding compared with those in the obturator approach group (10 [40%] vs 2 [8%], p = .01). Only two patients, both in the retropubic group, had voiding difficulties for longer than 1 week. One month after surgery, continence results did not differ significantly between the two groups (p = .30). In the retropubic approach group, 20 (80%) of the women were cured, and substantial improvement was experienced by 5 (20%). In the obturator approach group, these figures were 20 (83%) and 3 (12.5%), respectively, with one surgical failure (4%). Those initial results were unchanged at last follow-up (mean follow-up was 13.7 +/- 3 months for the retropubic approach group and 7.2 +/- 2 months for the obturator approach group). CONCLUSION: The obturator approach for suburethral slings is feasible and safe and may limit both preoperative and postoperative complications. Our short-term continence results compare well with those achieved with the retropubic approach. A randomized study is now needed to compare these two approaches.     

Women’s well-being after Manchester procedure for pelvic reconstruction with uterine preservation: a follow-up study

Purpose

This study describes the outcomes of a modified Manchester procedure on the quality of life and sexual functioning of women with elongation of the uterine cervix with or without pelvic organ prolapse (POP).

Methods

Data on medical and demographic variables were collected from medical files and then women were invited to for follow-up examination and data collection.

Results

Follow-up data were collected from 53 out of 87 women who underwent reconstructive surgery with modified Manchester procedure (60.9% of the women). Prior the surgery, all women in this sample (n?=?53) were medically examined and found to have uterine cervix elongation, 40/53 (75.4%) women also had cystocele, 10/53 women (18.8%) had uterine prolapse and 8/53 women (15.1%) had rectocele (all stages II–IV). On follow-up examination, all the cervical stumps were satisfactorily situated, recurrent cystocele was found among 12/53 women (22.6%) women; 13/53 (24.5%) had rectocele; and none of these women had uterine prolapse. Women with POP (cystocele and rectocele) (24/53) had less operative satisfaction (p?=?0.004), lower quality of life (p?p?=?0.03) compared to women without POP (29/53).

Conclusion

The modified Manchester procedure including reconstructive surgery for women with cervix elongation, with or without POP, prevented recurrent uterine prolapse and was well received in terms of patient’s satisfaction, quality of life, and sexual function.     

Impact of the mid-urethral sling for stress urinary incontinence on female sexual function and their partners’ sexual activity

Objective

To assess the impact of the transobturator mid-urethral sling (MUS) procedure on female sexual function and their partners’ sexual activity.

Treatment of vaginal dysplasia: just a simple loop electrosurgical excision procedure?

We report a case of sigmoid perforation, peritonitis, and adult respiratory distress syndrome after a loop excision procedure for carcinoma in situ of the cervix and dysplasia of the vagina. Treatment of vaginal dysplasia with loop excision is potentially dangerous. Safer methods of management include carbon dioxide laser, topical 5-fluorouracil, and fulguration.     

Lower urinary tract injury during the Burch procedure: is there a role for routine cystoscopy?

OBJECTIVE: This study was undertaken to evaluate the use of intraoperative cystoscopy for the detection of incidental bladder or ureteral injuries during abdominal urethropexy procedures and to determine whether the incidence of injuries warrants the routine use of cystoscopy. METHODS: We reviewed the medical records of 109 consecutive patients who underwent abdominal urethropexy procedures between November 1990 and February 1996 at a teaching institution. Each underwent intraoperative cystoscopy. We determined the incidence of cystotomy and ureteral obstruction and attempted to determine surgical factors that might be associated with an increased risk of injury. RESULTS: Ten of 109 patients (9%) had bladder or ureteral injury, including 1 cystotomy during retropubic dissection, 6 cases of a transvesical suture noted during cystoscopy, 1 cystotomy recognized before closure, 1 case of ureteral obstruction found during cystoscopy, and 1 case of ureteral obstruction not recognized at cystoscopy. Cystoscopy allowed detection of 7 of 9 (78%) otherwise unrecognized events. The only injury that resulted in significant postoperative morbidity was the unrecognized ureteral obstruction. There was no association between incidence of lower urinary tract injuries and surgical risk factors. CONCLUSION: Intraoperative bladder or ureteral injuries during urethropexy procedures are not uncommon, with an incidence of 9% in our series. There is minimal morbidity if these injuries are detected and corrected during the operation, whereas morbidity may be significant if they remain unrecognized. With a potential for unrecognized injury in 8% of Burch procedures without the use of cystoscopy, routine use of cystoscopy during urethropexy procedures appears to be warranted.     

Which factors influenced the result of a tension free vaginal tape operation in a single teaching hospital?

BACKGROUND: Tension free vaginal tape (TVT) has proven to be successful. Nevertheless, complications of the TVT have been reported. The aim of this study was to describe factors that might influence the efficacy and safety of the TVT procedure in our clinic. METHODS: Medical records of all patients who underwent TVT surgery between 1 January 2001 and 1 May 2004 were reviewed. To achieve subjective follow-up, in 2004 and 2005, we sent all patients standardised validated questionnaires. Data were analysed with SPSS. RESULTS: A total of 198 TVT procedures were performed. In 75 cases (37.9%), the procedure was combined with vaginal prolapse surgery. Complications were found in 19.7% of all TVT procedures. Most patients (71%) returned the questionnaire. Median follow-up was 27 months (range: 9-49). Subjective success rate was 73%. Logistic regression analysis showed that success rate of the TVT procedure was not influenced by any of the factors we studied. Complications were not more common in patients who had undergone prior incontinence or prolapse surgery. Concomitant prolapse surgery with the TVT, however, was found to be the only risk factor for complications, mainly prolonged catheterisation. CONCLUSIONS: In this study, we found no factor that influenced the success rate of the TVT. In the literature, the experience of the surgeon is marked as a factor influencing the success rate. We, therefore, gradually reduced the number of gynecologists who perform TVT. Concomitant prolapse surgery, however, was shown to be an independent risk factor for complications. Therefore, we prefer to 'separate' prolapse and incontinence surgery.     

Effect of vaginal metronidazole + miconazole treatment during pregnancy for gestational age and birth weight in a population-based study

The objective of the study was to check the effect of the combination of metronidazole and miconazole (M+M) for the prevention of sexually transmitted infections/disorders related preterm delivery/birth. Antiprotozoal vaginal metronidazole was not able to prevent preterm birth, while the antifungal topical miconazole use showed some reduction in preterm birth in our previous studies. The population-based large control (without any defects) data set of the Hungarian Case-Control Surveillance System of Congenital Abnormalities was used for the evaluation of the combination of M+M for birth outcomes. Of 38,151 controls, 846 (2.2%) had treatment with vaginal tablet of M+M for vaginal infections. The prevalence of preterm birth was 9.5% after this treatment compared with the 9.2% of preterm birth in the untreated group. Thus the combination of M+M was not able to reduce the preterm birth associated with vulvovaginal infections/disorders.     

Pre-birth characteristics and 5-year follow-up of women with cryopreserved embryos after successful in vitro fertilisation treatment

Many patients do not make a decision about the disposition of their surplus embryos until they are compelled to do so by statutory limits. In the current study, the characteristics of women who had conceived through in?vitro fertilisation (IVF) and who still had embryos stored (E-S; n?=?26) 5 years after IVF were compared to a cohort comparison group (C-C; n?=?40). At time 1 (T1, 28 weeks pregnant) women completed questionnaires on personality traits (anxiety, locus of control and dependency) and participated in an interview on socio-demographic characteristics, family composition and stored embryos. At T2 (5 years later) women were re-interviewed and asked about beliefs about the embryos. Women in the E-S group were significantly younger, had been married or living with their partner for fewer years and had had more children than the C-C group. Further, women in the E-S group were more likely to have an external locus of control and a dependent personality than women in the C-C group. Almost all women in the E-S group (88.5%) thought of their embryos as siblings to existing children, and reported thinking about the embryos occasionally (61.5%) or frequently (34.6%). The personality differences identified may suggest that women who still have embryos after the end of fertility treatment may be in need of decision support.     

The impact of CO2 laser for treatment of Bartholin’s gland cyst or abscess on female sexual function: a pilot study

The aim of this study is to evaluate the sexual functionality before and after treatment of Bartholin’s gland diseases (BGD) with CO₂ laser and to compare our results to patients who underwent surgical cold knife and to a healthy control group (HCG). Consecutive patients (n?=?15) affected by BG cyst or abscess who underwent CO₂ laser treatment were evaluated. Patients were asked to complete the Italian translation of the Female Sexual Functioning Index (FSFI) before and 4?weeks after treatment. Results after CO₂ laser were compared with two control groups: patients affected by BG cyst (n?=?15) or abscess treated with surgical cold knife treatment and a HCG (n?=?18). A statistically significant advantage of CO₂ laser versus cold knife treatment in terms of lubrication, pain and global score were recorded. Both the single scores of five domains and total score of FSFI were globally higher after any treatment compared to before (CO₂ and cold knife) of BGD. According to our data, CO₂ laser therapy is often well tolerated by patients and correlated with a favorable sexual health recovery.     

A randomized prospective comparison of the needleless mini-sling “hammock” and “U-shape” configurations for management of stress urinary incontinence: 18 month follow-up results

Objective

To compare the efficacy of needleless mini-sling placed either retropubic (U-shape) or trans-obturator (hammock-shape) to treat stress urinary incontinence.

Setting

One hundred and twenty six women were randomized in a 2:1 ratio to receive hammock-shaped or U-shaped of Contasure-NDL.

Methods

All surgical procedures were performed by one senior surgeon experienced in anti-incontinence surgery with mesh. Cough-stress test was considered for objective outcome. Subjective outcomes consisted of International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), Patient Global Impression of Improvement (PGI-I) and three-item Likert scale to measure satisfaction. Assessments were performed preoperatively and at postoperative 6th, 12th and 18th month.

Results

The objective cure rates at postoperative 6th and 12th month were significantly lower in U-shape group compared to hammock-shape group (85.4 vs. 96.4%; p?=?0.034) and was comparable with hammock-shape group at 18^th month postoperative (90.2 vs. 96.4%, respectively; p?=?0.216). The subjective cure rates at postoperative 6th, 12th and 18th month were similar between groups (90.2/90.2/100% vs. 96.4/96.4/96.4%, respectively; p?>?0.05). Median of total ICIQ-SF scores was significantly lower in hammock-shaped group (1.62?±?2.92) compared to U-shape (3.80?±?2.64) at 18th month (p?<?0.001). The rate of patients reported as very satisfied or satisfied to the Likert scale was 90.2% in U-shape group and 96.4% in hammock group. Patients’ responses to PGI-I were majorly distributed to “much better” and “very much better” with a mean score of 1.93?±?2 in U-shape and 1.33?±?1 in hammock group at 18th month of follow-up (p?<?0.001).

Conclusion

U-shape placement of needleless single-incision mini-sling mimicking the retropubic route did not satisfy in achieving the patient’s goal when compared to hammock-shape placement.

     

Obstetric care of Jehovah’s Witnesses: a 14-year observational study

Over a 14-year period, the obstetric outcome of Jehovah’s Witnesses in an inner city hospital was reviewed and the effect of refusal of blood on morbidity and mortality evaluated. Ninety women had 116 deliveries and of these, 24% were delivered by caesarean section, 10% had instrumental deliveries and 66% were normal vaginal deliveries. Postpartum haemorrhage of >1,000 mls occurred in 6% and postpartum anaemia was the commonest complication. The mean postdelivery haemoglobin (11.10 ± 1.15 g/dl) was not significantly less from the mean predelivery haemoglobin level (11.81 ± 1.62 g/dl) (P > 0.05, paired t test). The single maternal death occurred after caesarean hysterectomy, which when extrapolated, resulted in a 65-fold increased risk of maternal death compared to the national rate. The optimum management of pregnant women who decline transfusion is discussed.